Red River Regional Hospital


Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
504 Lipscomb Street
Bonham, Texas 75418
 It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       


Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Cell Phone Or Home Phone
Present Address

 Present City

 Present State

 Present Zip Code

E-Mail Address
Previous Address

 Previous City

 Previous State

 Previous Zip
Current Open Position(s) for Which You Are Applying
Type in name of the desired position:  


 Type of Position
Full Time
 PRN
Part Time
 Temporary
Shift

 Weekend
Day
 Night
Rotation
Salary Requirement
$
Are You Willing To Travel?

Are You Willing To Relocate?

If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked at Red River Regional Hospital?
If yes, when? If yes, under what name did you work? Are you related to another facility employee?
If yes, please provide name of relative, department they work in and your relationship.

How did you learn about this position?
State Employment
         Commission
 Internet
Agency
 Ad
Job Listing
 School
Current Employee
 Job Line
Other:

Will you request not to participate in any aspect of patient care, including treatment, because you perceive a conflict with your cultural values, ethics or religious beliefs?
If yes, please list the specific type of patients and the aspects of care or treatment in which you will not participate:
Have you ever been convicted of or plead guilty to a felony or misdemeanor? (excluding misdemeanor traffic violations)?If yes, please explain.
Do you have any criminal convictions or any pending criminal charges in any state?
If yes, please explain:
Have you ever had a summons, hearing, or court appearance related to your profession?
If yes, please explain:
Have you ever had a professional license, registration, or certification sanctioned, suspended, revoked, or placed on probation?
If yes, please explain:
Educational History
Type of School
 Name of School
City, State
 Check Last Year
Attended in School
Degree or Certificate
High School
 School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
 School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
 School:
    City:
   State:
1    2    3     4
Graduated? 		Degree:
Graduate
School
 School:
    City:
   State:
1    2     3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
1    2    3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
1    2    3    4
Graduated? 		Degree:
List any professional licenses, registration or certification you possess
(Include only the last 4 digits of your Driver's License, if applicable)

Have you volunteered your time and talents?
If yes, where?
Briefly describe volunteer work performed:

 Have you ever served in the armed forces?
Yes  No

Branch Served In:


Rank Held:


Dates of Service (you will need to provide a copy of your DD214)
From:
To:

List any military training (special skills, etc.)